Resolution of chronic refractory migraine and development of burning mouth syndrome after focused ultrasound thalamotomy: illustrative case.

BACKGROUND: Chronic migraine is a highly disabling neurological disorder. A subset of patients develop chronic daily headaches refractory to all standard therapies. MR-guided focused ultrasound (MRgFUS) ventral intermediate nucleus (VIM) thalamotomy is an incisionless treatment for medication-refractory essential tremor (ET).

OBSERVATIONS: A 76-year-old woman with a 40-year history of chronic migraine with near-daily attacks, characterized predominantly by right-sided headaches and unresponsive to multiple preventive and acute treatments, underwent MRgFUS VIM thalamotomy for severe ET. After the procedure, her tremor resolved, and her chronic migraines were no longer reported during long-term follow-up. Shortly after the procedure, she developed burning mouth syndrome (BMS), characterized by bilateral oral burning dysesthesias with left-sided predominance involving the lips and oral mucosa. She was treated with gabapentin and amitriptyline, with partial symptomatic improvement. Postprocedure MRI confirmed the intended VIM lesion with slight medial extension toward the adjacent ventral posteromedial nucleus (VPM) of the thalamus, which relays trigeminal somatosensory input.

LESSONS: This unique case illustrates that ablative neuromodulation of thalamic networks may be followed by marked improvement or remission of chronic refractory migraine, further supporting a possible role for the thalamus in migraine pathophysiology and pain transmission. It also highlights a potential trade-off: lesion extension toward nearby sensory nuclei, including the VPM, may be associated with focal central pain manifesting as BMS. https://thejns.org/doi/10.3171/CASE251040.